• TOSA PEDIATRICS

    TOSA PEDIATRICS

    Mental Health Informed Consent for Psychotherapy and/or Medication Management
  • General Information:

    The therapeutic relationship is unique in that it is both personal and professional. It is important to establish a clear understanding of how treatment will proceed and what can be expected from both the client and the provider. This document outlines important information regarding psychotherapy and psychiatric medication management services. Please review carefully and discuss any questions with your provider prior to signing.

    The Therapeutic Process:

    Engaging in therapy and/or medication management is a positive step toward improving mental health and overall well-being. Treatment outcomes depend significantly on a client’s active participation and commitment to the process. At times, therapy may involve discussing or recalling difficult experiences, which can evoke strong emotions such as sadness, anger, or anxiety.

    While no specific results can be guaranteed, providers are committed to supporting clients, working to understand their experiences and patterns, and assisting in clarifying treatment goals.

    Medication Management:
    Psychiatric medications may be recommended as part of treatment. The purpose of these medications is to reduce or manage symptoms, improve daily functioning, and support overall treatment goals.

    Potential Benefits:

    • Reduction of mental health symptoms 
    • Improved functioning and quality of life 
    • Enhanced ability to engage in psychotherapy and daily activities


    Possible Risks and Side Effects:

    • Common: fatigue, appetite or weight changes, gastrointestinal upset, headaches
    • Less common: changes in blood pressure, sexual side effects, movement-related symptoms
    • Rare but serious: allergic reactions, worsening mood or suicidal thoughts (especially in younger clients), organ toxicity, cardiac concerns


    Alternatives:

    • Psychotherapy without medication
    • Lifestyle interventions such as exercise, nutrition, and sleep management
    • Other non-medication approaches


    Client Responsibilities:

    • Take medications exactly as prescribed
    • Report any side effects or new symptoms promptly
    • Inform providers of all medications, supplements, and substances being used
    • Attend scheduled follow-up and monitoring appointments
    • Refrain from stopping medications abruptly without medical guidance

    Medication Refill Requests:


    Refill requests must be submitted during regular business hours, which are Tuesdays through Fridays, 9:00 am to 5:00 pm. Requests made outside of these hours, including evenings, weekends, and holidays, will not be reviewed or processed until the next business day.


    In the event of an urgent medication issue, such as a spilled liquid prescription or other emergency that cannot wait until regular hours, patients may contact the on-call service for guidance. Please note that the on-call service is intended for true emergencies and may not be able to authorize routine refills.


    By signing below, you acknowledge and agree to follow the refill request procedure as outlined above.

    Confidentiality:


    Information shared in treatment is confidential and will not be released without the client’s written consent, except as required by law. Circumstances in which confidentiality may be broken include:

    1. Threats or attempts of suicide or serious self-harm
    2. Threats of grave bodily harm to another person
    3. Reasonable suspicion of abuse or neglect of a child, elder, or vulnerable adult
    4. Compliance with a legitimate subpoena or court order
    5. Treatment that is court-ordered or requires a professional report
    6. Consultation with other professionals (with identifying information protected whenever possible)

    In situations where clients and providers encounter each other outside of the professional setting, providers will not initiate contact in order to protect client confidentiality. If the client chooses to acknowledge the provider, interactions will remain brief and non-clinical.

    Communication & Social Media Policy:

    • Providers do not engage with clients through social media. Friend or follow requests cannot be accepted.
    • Email communication may be used for logistical or informational purposes but is not appropriate for clinical discussions or urgent concerns.
    • Urgent or life-threatening concerns should never be communicated via email. 
    • Clients experiencing an emergency should call 911 or go to the nearest emergency department.


    Client Rights:

    Clients receiving mental health or substance use services in Wisconsin are guaranteed certain rights, including but not limited to:

    1. To be treated with dignity and respect, free from abuse or discrimination.
    2. To have fair and reasonable decisions made regarding treatment.
    3. To participate in treatment planning and decision-making.
    4. To receive prompt, adequate, and appropriate treatment.
    5. To be fully informed of potential benefits, risks, and alternatives to treatment.
    6. To give or withhold consent for treatment, except in emergencies.
    7. To be informed of treatment costs and to discuss fees.
    8. To confidentiality of records, except where disclosure is required by law.
    9. To access treatment records and request corrections.
    10. To file informal complaints or formal grievances if rights are violated.


    For formal grievances, contact: Ashley Hall, Practice Manager — 414-774-9200

    A full brochure outlining client rights in Wisconsin is available upon request.

    Emergency Procedures:

    In the event of a life-threatening emergency, severe side effects, or thoughts of harming oneself or others, clients should call 911 or proceed to the nearest emergency department immediately.

    Consent:

    I have reviewed and understand the information provided in this document. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction. I understand the potential benefits, risks, and alternatives to psychotherapy and/or psychiatric medication management, as well as my rights and responsibilities as a client. I voluntarily consent to participate in treatment and/or consent for my child to participate.

    FOR PARENTS/GUARDIANS OF CHILDREN: BY SIGNING BELOW I AM ATTESTING THAT I HAVE THE LEGAL RIGHT TO CONSENT TO TREATMENT FOR THIS CHILD.


    BY  SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

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